Medicine still a noble calling, despite outside interference

In the Residency to Retirement column published in the January Bulletin, “Is medicine still a good profession? Reflections of a retired surgeon,” Paul Jordan, MD, FACS, presented a strong case in favor of a medical career.1 I would tend to agree and believe that there are several aspects of surgical practice that affect one’s perception of the worthiness of making it one’s life’s work.

A calling to serve

The practice of medicine and surgery has long been considered a “profession” or a “calling.” A profession may be defined as “a vocation or occupation requiring advanced education and training, and involving intellectual skills, [such] as medicine.” A calling is “one’s occupation, profession, or trade” or “an inner urging toward some profession or activity.”2

One is often drawn to a life of service to others—such as entering religious studies to become a priest, nun, minister, or rabbi, or perhaps applying to schools to become a nurse or physician. The compulsion to pursue these fields may be the result of examples set by a family member or close friend, a personal epiphany, or an answer to prayers. Young men and women often aspire to study and practice medicine or one of its specialties due to an interest in the welfare and well-being of others and a desire to provide care to people suffering from physical or mental afflictions. This interest may also be derived from an aptitude for the biological sciences or information gleaned from reading, the Internet, or other sources.

In most cases, the medical student sees his or her life’s work as providing care or service to patients in the purest altruistic sense. Only later, when frustrating experiences as a clinical clerk, intern, resident, or fellow leaven this initial enthusiasm to always “do good,” is the aspiring physician faced with the reality of sometimes conflicting choices over what is in the patient’s best interests. These decisions may require a confrontation with the payor, including government programs and private insurers, and may result in situations that are stressful and less financially rewarding or convenient for the physician. At that point, the physician begins to become a “businessperson” and perhaps less of a physician.

In my medical school class, the majority of freshman students aspired to be primary care physicians. By the time we were in our senior year and ready to select our residency programs, though, most (nearly 80 percent) had chosen to enter a specialty rather than primary care. Many of these decisions were undoubtedly based upon the more favorable economics of specialty practice or lifestyle choices. However, 33 of our class of 110 selected general surgery or a surgical subspecialty.

The business of medicine

Although most physicians have faced the “business versus profession” dilemma, to our credit, day in and day out, we generally have given our patients our best efforts on their behalf and resisted as much as possible interference from insurers and the government in the health care decision-making process. In the final analysis, physicians who see the practice of medicine or surgery as a true profession, one of giving service to others, and who remain true to that calling, will be satisfied and grateful for the opportunity to earn their patients’ trust. Those whose primary interest is in running their practice as a business with fealty to the bottom line will probably enjoy less spiritual or intellectual fulfillment.

In The Kitchen Shrink: A Psychiatrist’s Reflections on Healing in a Changing World, Dora Calott Wang, MD, an academic psychiatrist, laments the disintegration of the traditional physician-patient relationship and its replacement with a corporate, bottom line-driven health care system. “Doctors never used to sign off. Doctors once delivered patients from the womb, then cared for them through their lives…. Like family, the doctor-patient relationship was once a faithful one, until death did us part,” she writes.3

Dr. Wang writes about a conversation she had with a colleague who said, “The insurance companies make the decisions and physicians take the heat…,” to which she replied, “American medicine, a charitable enterprise to which society once contributed money, is now an industry from which profits are taken. During my years in medicine, I have witnessed it become an expensive system rigged toward not paying for health care.” Resisting this change and with a look toward the future, Dr. Wang tells one of her medical students, “Do all you can for your patients…. Never treat medicine as just a job, because then that’s all you’ll ever have, just a job.”3

Before the era of managed care began in the 1980s, most physicians offered a significant portion of their services gratis to the neediest of their patients. They did so with honor, dedication, pride, and a sense of mission. Now, in the era of escalating costs of running a practice and declining reimbursement from private and public health insurance plans, the physician is being squeezed financially to the point where sharp business practices have come to occupy a place of prominence in the successful medical or surgical practice, while truly needy, financially disenfranchised, or uninsured patients have been allowed to slip through the cracks.

Those of us who practiced in the fee-for-service era initially and now practice in the managed care era find frustrating the loss of freedom to practice in a manner that most benefits the patient. The demand for adherence to the countless rules and regulations of government-run health care programs, such as Medicare and Medicaid, and the many employer-sponsored insurance plans that pay most of the (discounted) fees for our services, all too often, unintentionally or not, get in the way of good medical/surgical care.

Trend toward employment

An increasing number of physicians and surgeons are seeking employment in large, incorporated medical/surgical practices or choosing to become salaried hospital employees, or “hospitalists,” to avoid dealing with the escalating costs of running a practice. The solo practitioner or small group practice, even in small towns and rural areas, is rapidly becoming an endangered species.

Hopefully, training programs developed specifically for the rural surgeon will reverse this trend.
Those of us who practiced part or all of our careers in the era of fee for service have a hard time accepting the concept of managed care, when those individuals responsible for making decisions about what is a covered service often are nonphysicians. We question whether some of these individuals are able to decide what is in the patient’s best interests rather than what is best for the corporate bottom line.

Recent medical school graduates who have no personal experience with fee for service will have less difficulty accepting the new medical care model, one of fealty to bureaucratically determined guidelines in which the physician is a “provider,” an employee who works a shift and offers covered services to patients who have been enrolled in a health care plan. Such a situation, unfortunately, could destroy the sacred trust that patients have placed in their physician as someone who is primarily entrusted with their best interests with respect to health care matters. Physicians in this new era must remember and jealously guard their role as their patients’ advocate vis-a-vis the government and private health care insurance plans. If physicians continue to advocate for their patients, the bond between patient and physician may be preserved.

Encouraging the next generation

What does the physician/surgeon tell his or her children about the advisability of pursing a career in medicine? In spite of a recent survey that showed that a majority of physicians “were unwilling to recommend health care as profession,” many physicians’ children continue to become physicians themselves, and they are happy with their decision.4 They knew what was going on in their parent’s professional life and still made the decision to join up.

If a child expresses interest in a parent’s profession, the parent must have done something to pique that interest. Parents should be honest in their description of their satisfaction, or lack thereof, with their life’s work. Discuss the good aspects—
service, dedication, altruism, patient trust, satisfaction in a job well done, good income—as well as the drawbacks—long hours, selflessness, and sacrifice in one’s personal life, dissatisfaction with governmental or other bureaucratic restraints, the high costs of maintaining a practice.

In the end, children are notorious for resisting their parents’ advice. So, if 90 percent of 5,000 physicians who participated in a study4 advised their children not to enter medicine, maybe more of them will become physicians. None of my three children followed in my footsteps. However, one daughter is a hospital administrator and another daughter managed a freestanding plastic surgery center for 10 years and now works in a biomedical research facility. Having a physician as their father undoubtedly influenced their decisions to enter the medical field, albeit not as physicians. Most importantly, they are all happy in their lives, and that is the most a good parent can wish for his or her children.

Rather than recall the glory days of the past, which are only memories to those of us who entered practice then, let us look to the future. We must find ways to continue to inspire our medical students to envision their professional careers as a call to serving with dedication and self-sacrifice for their patients. In this way, the practice of medicine will again be a fulfilling profession and not just a job. Likewise, the foundation of their practices will be the physician-patient relationship and not an industry or a system.

References

Jordan PH. Is medicine still a good profession? Reflections of a retired surgeon. Bull Am Coll Surg. 2013;98(1):58-60.